DOCUMENTS REQUIRED FOR YOUR RECERTIFICATION PACKET · 1A Lowndes Avenue Huntington Station, N.Y. 11746 (631) 427-6220 - Fax (631) 427-6288 DOCUMENTS REQUIRED FOR YOUR RECERTIFICATION

1A Lowndes Avenue Huntington Station, N.Y. 11746 (631) 427-6220 - Fax (631) 427-6288

DOCUMENTS REQUIRED FOR YOUR RECERTIFICATION PACKET

If any member of your household receives any of the following types of income listed below, please provide the following: Mailing name, address and telephone number of the source of income and documentation about current amounts received. (For example, Award Letters, copies of paystubs).

I. INFORMATION ABOUT YOUR HOUSEHOLD INCOME AND ASSETS: A) EMPLOYMENT INCOME – FOR EVERY MEMBER OF YOUR HOUSEHOLD

THAT IS WORKING, PLEASE PROVIDE THE FOLLOWING:

1. Paystubs – Current & consecutive (Four if paid weekly or two if paid bi-weekly/semi-monthly).

2. Latest W-2 Forms 3. Copy of your most recent Tax Return 4. Other types of expected income such as tips, overtime, commissions, profit sharing programs, etc.

B) BENEFIT & SUPPORT INCOME: PROOF MUST BE CURRENT!

1. Unemployment Benefits – WEEKLY PRINTOUT 2. CURRENT Social Security Award Letter – NO MORE THAN 30 DAYS 3. Supplemental Social Security Award Letter – NO MORE THAN 30 DAYS 4. Child Support - WEEKLY OR MONTHLY PRINTOUT 5. Public Assistance and/or Food Stamps – CURRENT BUDGET PRINTOUT 6. Pension, Annuities, Disability Income, Workmen’s Compensation, Alimony,

etc. 7. Regular Support from family members and/or friends.

C) BANK STATEMENTS – Three consecutive bank statements for all accounts for all

family members over 18 (i.e., Checking, savings, CDs, etc.)

D) STOCKS/BONDS – Current statement indicating VALUE of stock, and dividend amount.

E) LIFE INSURANCE – Cash surrender value only (please attach table of cash value).

(CONTINUED ON NEXT PAGE).

II. FULL TIME COLLEGE STUDENT STATUS – Please provide a LETTER from the school’s REGISTRAR OFFICE indicating current F/T student status (DO NOT provide an acceptance letter, bill or schedule).

III. MEDICAL EXPENSES – If you or your spouse are 62 years of age; or disabled; or

handicapped and you have medical expenses that exceed your insurance coverage, please provide documentation that the medical bills have been paid including the actual bill and copies of cancelled checks, receipts, etc. If you have outstanding medical bills and you have entered into repayment agreement with your doctor or hospital, please provide the name and address of the doctor or hospital in order that we can verify a repayment agreement and send a copy of the agreement with proof of payment each month (i.e. canceled checks). Note: Medical expenses only apply if head of household or spouse is 62 years of age or older or disabled or handicapped. Documentation of medical must be provided. Examples of medical expenses are:

-Medical coverage (If you receive Medicare, provide previous years).

TOWN OF HUNTINGTON HOUSING AUTHORITY 1-A LOWNDES AVENUE ● HUNTINGTON STATION, NY 11746 ● 631-427-6220 ● FAX 631-427-6288

Dear Tenant:

IN ACCORDANCE WITH FEDERAL LAW, THIS OFFICE MAY TERMINATE RENTAL ASSISTANCE TO TENANT/FAMILY FOR THE FOLLOWING REASONS:

o IF THE FAMILIY VIOLATES ANY FAMILY OBLIGATIONS UNDER THE PROGRAM. o IF THE FMAILY FAILS TO NOTIFY SECTION 8 IN WRITING OF ALL INCOME AND FAMILY

COMPOSITION CHANGES IMMEDIATELY. o IF ANY MEMBER OF THE FAMILY HAS BEEN EVICTED FROM PUBLIC HOUSING. o IF A HOUSING AUTHORITY HAS EVER TERMINATED ASSISTANCE UNDER THE HOUSING CHOICE

VOUCHER PROGRAM FOR ANY MEMBER OF THE FAMILY. o IF ANY MEMBER OF THE FAMILY COMMITS DRUG-RELATED CRIMINAL ACTIVITY, OR VIOLENT

CRIMINAL ACTIVITY. o IF ANY MEMBER OF THE FAMILY COMMITS FRAUD, BRIBERY OR ANY OTHER CORRUPT OF

CRIMINAL ACT IN CONNECTION WITH FEDERAL HOUSING PROGRAM. o IF ANY FAMILY CURRENTLY OWES RENT OR OTHER AMOUNTS TO HUNTINGTON HOUSING

AUTHORITY OR TO ANOTHER HOUSING AUTHORITY IN CONNECTION WITH THE SECTION 8 OR PUBLIC HOUSING AUTHORITY UNDER THE UNITED STATES HOUSING ACT OF 1937.

o IF THE FAMILY HAS NOT REIMBURSED ANY HOUSING AUTHORITY FOR AMOUNTS PAID TO AN OWNER UNDER A HAP CONTRACT FOR RENT, DAMAGES TO THE UNIT, OR OTHER AMOUNTS OWED BY THE FAMILY UNDER THE LEASE.

o IF THE FAMILY BREACHES AN AGREEMENT WITH HHA TO PAY AMOUNTS OWED TO HHA OR AMOUNTS PAID TO AN OWNER BY HHA (HHA AT ITS DISCRETION MAY OFFER A FAMILY THE OPPORTUNITY TO ENTER AN AGREEMENT TO PAY AMOUNTS OWED TO HHA OR AMOUNTS PAID TO AN OWNER BY HHA.) HHA MAY PRESCRIBE THE TERMS OF THE AGREEMENT.

o IF THE FAMILY HAS ENGAGED IN THREATENING, ABUSIVE, OR VIOLENT BEHAVIOR TOWARDS THE HHA PERSONNEL.

IF YOUR ASSISTANCE IS TERMINATED FOR ONE OF THE ABOVE REASONS, BOTH YOU AND THE OWNER WILL BE PROVIDED WITH A 30 DAY WRITTEN NOTICE OF TERMINATION WHICH STATES:

o THE REASONS FOR THE TERMINATION. o THE EFFECTIVE DATE OF THE TERMINATION. o THE FAMILY’S RIGHT TO REQUEST AN INFORMAL HEARING.

ANYONE 18 OR OLDER MUST SIGN BELOW. I HAVE READ THE ABOVE AND UNDERSTAND WHAT I HAVE READ. ______________________________ ____________ ___________________________ ____________ HEAD OF HOUSEHOLD DATE SPOUSE/CO-HEAD DATE ______________________________ ____________ ___________________________ ____________

OTHER ADULT DATE OTHER ADULT DATE !


PERSONAL DECLARATION

THIS FORM MUST BE COMPLETED IN INK IN YOUR OWN HANDWRITING. YOU MUST USE THE CORRECT NAME FOR EACH MEMBER OF YOUR HOUSEHOLD. ALL ADULT MEMBERS OF THE HOUSEHOLD MUST SIGN BELOW CERTIFYING THE INFORMATION PERTAINING TO THEM. PLEASE PRINT CLEARLY.

I. HOUSEHOLD COMPOSITION: LIST ALL PERSONS WHO ARE LIVING IN YOUR HOME, LISTING THE HEAD OF HOUSEHOLD FIRST.

ADULTS (LEGAL NAME)

DATE OF BIRTH

RELATIONSHIP TO HOH

SOCIAL SECURITY #

INDICATE: (M) MARRIED

(S) SEPARATED (D) DIVORCED

HOUSEHOLD MEMBER IN COLLEGE?

YES/NO 1.

2.

3.

4.

5.

CHILDREN (NAME AS IT APPEARS ON

SS CARD)

DATE OF BIRTH

RELATIONSHIP TO HOH

SCHOOL NAME ABSENT PARENT’S

NAME

ABSENT PARENT’S ADDRESS

1.

2.

3.

4.

5.

6.

7.

8.

PRESENT ADDRESS EMERGENCY CONTACT

_____________________________________________ ____________________________________________

NAME NAME

_____________________________________________ ____________________________________________ STREET ADDRESS STREET ADDRESS

_____________________________________________ ___________________________________________ CITY, STATE, ZIP CITY, STATE, ZIP

_____________________________________________ ____________________________________________ PHONE # PHONE #

II. TOTAL HOUSEHOLD INCOME: LIST ALL MONEY EARNED OR RECEIVED BY EVERYONE LIVING IN YOUR HOUSEHOLD THAT INCLUDES MONEY FROM WAGES, SELF-EMPLOYMENT, CHILD SUPPORT, CONTRIBUTIONS, SOCIAL SECURITY, DISABILITY PAYMENT, WORKERS COMPENSATION, RETIREMENT BENEFITS, TANF, VETERAN’S BENEFITS, RENTAL PROPERTY INCOME, STOCK DIVIDENDS FROM BANK ACCOUNTS, ALIMONY AND ALL OTHER SOURCES.

LIST AMOUNTS RECEIVED BELOW:

HOUSEHOLD MEMBER

EMPLOYER TOTAL WEEKLY WAGES

TANF BENEFITS

CHILD SUPPORT

MONTHLY

SOCIAL SECURITY BENEFITS

UNEMPLOYMENT BENEFITS

ALL OTHER INCOME

1.

2.

3.

4.

5.

III. ASSETS: IF YES TO ANY, LIST BELOW.

1. DO YOU OR ANY HOUSEHOLD MEMBERS OWN OR HAVE AN INTEREST IN ANY REAL ESTATE, HOMES AND/OR MOBILE HOME? YES/ NO 2. HAVE YOU SOLD ANY REAL ESTATE IN THE LAST TWO YEARS? YES/NO 3. DO YOU OWN ANY SAVINGS ACCOUNT? YES/ NO IF YES, LIST BANK ACCOUNT NUMBERS AND AMOUNTS._____________________________________________ 3. DO YOU OWN A CAR? YES /NO MODEL/YEAR______________ LICENSE PLATE # _____________ 4. DOES ANYONE OUTSIDE OF YOUR HOUSEHOLD PAY FOR ANY OF YOUR BILLS OR GIVE YOU MONEY?

YES/NO IF YES, EXPLAIN: _______________________________________________________________________________________ 5. HAVE YOU OR ANY OTHER ADULT MEMBERS EVER USED ANY NAME(S) OR SOCIAL SECURITY NUMBER(S) OTHER THAN THE ONE YOU ARE CURRENTLY USING? YES/NO

IF YES, EXPLAIN: _______________________________________________________________________________________

6. HAVE YOU OR ANY OTHER MEMBERS LIVED IN ANY ASSISTED HOUSING? YES/NO IF YES, EXPLAIN: _______________________________________________________________________________________

7. HAVE YOU OR ANYONE IN YOUR HOUSEHOLD EVER BEEN ARRESTED, CHARGED, AND/OR CONVICTED OF ANY CRIME OTHER THAN A TRAFFIC VIOLATION? YES/NO

IF YES, LIST WHERE AND WHEN: ________________________________________________________________________

8. HAVE YOU EVER COMMITTED ANY FRAUD IN A FEDERALLY ASSISTED HOUSING PROGRAM OR BEEN REQUESTED TO REPAY MONEY FOR KNOWINGLY MISREPRESENTING INFORMATION FOR SUCH HOUSING PROGRAMS? YES/NO IF YES, EXPLAIN: _______________________________________________________________________________________

________________________________________________________________________________________________________________________ I DO HEREBY SWEAR AND ATTEST THAT ALL OF THE INFORMATION ABOVE ABOUT IS TRUE AND CORRECT. I ALSO UNDERSTAND THAT ALL CHANGES IN THE INCOME OF ANY MEMBER OF THE HOUSEHOLD AS WELL AS ANY CHANGES IN THE HOUSEHOLD MEMBERS MUST BE REPORTED TO THE HUNTINGTON HOUSING AUTHORITY IN WRITING IMMEDIATELY. ______________________________________ ___________ ________________________________________ ___________ SIGNATURE OF HEAD OF HOUSEHOLD DATE SIGNATURE OF CO-HEAD OF HOUSEHOLD DATE ______________________________________ ___________ ________________________________________ ___________ SIGNATURE OF OTHER ADULT DATE SIGNATURE OF OTHER ADULT DATE WARNING: TITLE 18, SECTION 1001 OF THE UNITED STATES CODE STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES.

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Persons who apply for or receive assistance under the followingprograms are required to sign this consent form:

PHA-owned rental public housingTurnkey III Homeownership OpportunitiesMutual Help Homeownership OpportunitySection 23 and 19(c) leased housingSection 23 Housing Assistance PaymentsHA-owned rental Indian housingSection 8 Rental CertificateSection 8 Rental VoucherSection 8 Moderate Rehabilitation

Failure to Sign Consent Form: Your failure to sign the consentform may result in the denial of eligibility or termination ofassisted housing benefits, or both. Denial of eligibility or termi-nation of benefits is subject to the HA’s grievance procedures andSection 8 informal hearing procedures.

Sources of Information To Be ObtainedState Wage Information Collection Agencies. (This consent islimited to wages and unemployment compensation I have re-ceived during period(s) within the last 5 years when I havereceived assisted housing benefits.)

U.S. Social Security Administration (HUD only) (This consent islimited to the wage and self employment information and pay-ments of retirement income as referenced at Section 6103(l)(7)(A)of the Internal Revenue Code.)

U.S. Internal Revenue Service (HUD only) (This consent islimited to unearned income [i.e., interest and dividends].)

Information may also be obtained directly from: (a) current andformer employers concerning salary and wages and (b) financialinstitutions concerning unearned income (i.e., interest and divi-dends). I understand that income information obtained from thesesources will be used to verify information that I provide indetermining eligibility for assisted housing programs and the levelof benefits. Therefore, this consent form only authorizes releasedirectly from employers and financial institutions of informationregarding any period(s) within the last 5 years when I havereceived assisted housing benefits.

Authority: Section 904 of the Stewart B. McKinney HomelessAssistance Amendments Act of 1988, as amended by Section 903of the Housing and Community Development Act of 1992 andSection 3003 of the Omnibus Budget Reconciliation Act of 1993.This law is found at 42 U.S.C. 3544.

This law requires that you sign a consent form authorizing: (1)HUD and the Housing Agency/Authority (HA) to request verifi-cation of salary and wages from current or previous employers; (2)HUD and the HA to request wage and unemployment compensa-tion claim information from the state agency responsible forkeeping that information; (3) HUD to request certain tax returninformation from the U.S. Social Security Administration and theU.S. Internal Revenue Service. The law also requires independentverification of income information. Therefore, HUD or the HAmay request information from financial institutions to verify youreligibility and level of benefits.

Purpose: In signing this consent form, you are authorizing HUDand the above-named HA to request income information from thesources listed on the form. HUD and the HA need this informationto verify your household’s income, in order to ensure that you areeligible for assisted housing benefits and that these benefits are setat the correct level. HUD and the HA may participate in computermatching programs with these sources in order to verify youreligibility and level of benefits.

Uses of Information to be Obtained: HUD is required to protectthe income information it obtains in accordance with the PrivacyAct of 1974, 5 U.S.C. 552a. HUD may disclose information(other than tax return information) for certain routine uses, such asto other government agencies for law enforcement purposes, toFederal agencies for employment suitability purposes and to HAsfor the purpose of determining housing assistance. The HA is alsorequired to protect the income information it obtains in accordancewith any applicable State privacy law. HUD and HA employeesmay be subject to penalties for unauthorized disclosures or im-proper uses of the income information that is obtained based on theconsent form. Private owners may not request or receiveinformation authorized by this form.

Who Must Sign the Consent Form: Each member of yourhousehold who is 18 years of age or older must sign the consentform. Additional signatures must be obtained from new adultmembers joining the household or whenever members of thehousehold become 18 years of age.

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Kimberly LaCrette

Town of Huntington Housing Authority1-A Lowndes AvenueHuntington Station, NY 11746

Kimberly LaCrette

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Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form forthe purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that HAs thatreceive income information under this consent form cannot use it to deny, reduce or terminate assistance without firstindependently verifying what the amount was, whether I actually had access to the funds and when the funds were received. Inaddition, I must be given an opportunity to contest those determinations.

This consent form expires 15 months after signed.

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Penalties for Misusing this Consent:

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Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this informationby the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the FairHousing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants andparticipants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income andother information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your familywill pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoringHUD-assisted housing programs, to protect the Government’s financial interest, and to verify the accuracy of the information you provide.This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatoryinvestigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permittedor required by law. Penalty: You must provide all of the information requested by the HA, including all Social Security Numbers you,and all other household members age six years and older, have and use. Giving the Social Security Numbers of all household memberssix years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provideany of the requested information may result in a delay or rejection of your eligibility approval.


Request Date: ___________________________ Name: ____________________________________________________________________ LAST FIRST MIDDLE CURRENT ADDRESS: __________________________________________________ __________________________________________________ PREVIOUS ADDRESS: __________________________________________________ __________________________________________________ SOCIAL SECURITY #: __________________________________________________ DATE OF BIRTH: __________________________________________________ EMPLOYER: __________________________________________________ I HEREBY AUTHORIZE HUNTINGTON HOUSING AUTHORITY TO OBTAIN INFORMATION IT DEEMS DESIRABLE IN THE PROCESSING OF MY APPLICATION, INCLUDING CREDIT REPORT, CIVIL OR CRIMINAL ACTION, RENTAL HISTORY OF EMPLOYMENT/SALARY DETAIL, AND ANY OTHER RELEVANT INFORMATION; AND RELEASE HUNTINGTON HOUSING AUTHORITY ITS’ EMPLOYEES AND AGENT FROM ALL LIABILITIES AND DAMAGE, WHATEVER INCURRED IN FURNISHING OR OBTAIN SUCH INFORMATION. ______________________________________________ __________________ HEAD OF HOUSEHOLD DATE ______________________________________________ __________________ SPOUSE/CO-HEAD DATE ______________________________________________ __________________ OTHER ADULT DATE ______________________________________________ __________________ OTHER ADULT DATE


Request Date: ___________________________ Name: ____________________________________________________________________ LAST FIRST MIDDLE CURRENT ADDRESS: __________________________________________________ __________________________________________________ PREVIOUS ADDRESS: __________________________________________________ __________________________________________________ SOCIAL SECURITY #: __________________________________________________ DATE OF BIRTH: __________________________________________________ EMPLOYER: __________________________________________________ I HEREBY AUTHORIZE HUNTINGTON HOUSING AUTHORITY TO OBTAIN INFORMATION IT DEEMS DESIRABLE IN THE PROCESSING OF MY APPLICATION, INCLUDING CREDIT REPORT, CIVIL OR CRIMINAL ACTION, RENTAL HISTORY OF EMPLOYMENT/SALARY DETAIL, AND ANY OTHER RELEVANT INFORMATION; AND RELEASE HUNTINGTON HOUSING AUTHORITY ITS’ EMPLOYEES AND AGENT FROM ALL LIABILITIES AND DAMAGE, WHATEVER INCURRED IN FURNISHING OR OBTAIN SUCH INFORMATION. ______________________________________________ __________________ HEAD OF HOUSEHOLD DATE ______________________________________________ __________________ SPOUSE/CO-HEAD DATE ______________________________________________ __________________ OTHER ADULT DATE ______________________________________________ __________________ OTHER ADULT DATE

TOWN OF HUNGTINGTON HOUSING AUTHORITY 1-A LOWNDES AVENUE ● HUNTINGTON STATION, NY 11746 ● PHONE 631-427-6220 ● FAX 631-427-6288

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APPLICANT/TENANT CERTIFICATION

APPLICANT(S’)/TENANT(S’) STATEMENT I/WE CERTIFY THAT THE INFORMATION GIVEN TO THE TOWN OF HUNTINGTON HOUSING AUTHORITY AGENCY ON HOUSEHOLD COMPOSITION, INCOME THAT NET FAMILY ASSETS AND ALLOWANCES AND DEDUCTIONS IS ACCURATE AND COMPLETED THE BEST OF MY KNOWLEDGE AND BELIEF. I/WE UNDERSTAND THAT FALSE STATEMENTS OR INFORMATION ARE PUNISHABLE UNDER FEDERAL AND/OR STATE LAW. I/WE ALSO UNDERSTAND THAT FALSE STATEMENTS OR INFORMATION ARE GROUNDS FOR TERMINATION OF HOUSING ASSISTANCE AND TERMINATION OF TENANCY. _________________________________________ ___________________ SIGNATURE OF HEAD OF HOUSEHOLD DATE _________________________________________ ___________________ SIGNATURE OF SPOUSE DATE _________________________________________ ___________________ SIGNATURE OF OTHER ADULT DATE _________________________________________ ___________________ SIGNATURE OF OTHER ADULT DATE IF YOU BELIEVE YOU HAVE BEEN DISCRIMINATED AGAINST, YOU MAY CALL THE FAIR HOUSING AND EQUAL OPPORTUNITY NATIONAL TOLL-FREE HOTLINE AT 800-424-8590. (WITHIN THE WASHINGTON D.C.- METROPOLITAN AREA, CALL 426-3500.) *AFTER VERIFICATION BY THIS HOUSING AGENCY, INFORMATION WILL BE SUBMITTED TO THE DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT ON FORM HUD-50058 (TENANT DATA SUMMARY), A COMPUTER-GENERATED FACSIMILE OF THE FORM OR ON MAGNETIC TAPE. SEE THE FEDERAL, PRIVACY ACT STATEMENT FOR MORE INFORMATION ABOUT ITS USE.

Kimberly LaCrette

Kimberly LaCrette

TOWN OF HUNTINGTON HOUSING AUTHORITY

TOWN OF HUNTINGTON HOUSING AUTHORITY 1-A LOWNDES AVENUE ● HUNTINGTON STATION, NY 11746 ● PHONE 631-427-6220 ● FAX 631-427-6288!

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EMPLOYMENT VERIFICATION FORM DATE: _____________________

APPLICANT/TENANT (PRINT NAME): ________________________________________________________

EMPLOYER’S NAME: _______________________________________________________________________

EMPLOYER’S ADDRESS: ________________________________________________________________

________________________________________________________________

I HEREBY AUTHORIZE MY EMPLOYER TO RELEASE ALL OF MY INCOME INFORMATION TO THE TOWN OF HUNTINGTON HOUSING AUTHORITY.

SOCIAL SECURITY NUMBER:_________________________________________________

SIGNATURE OF APPLICANT/TENANT:_______________________________________________________

FOR EMPLOYER’S USE ONLY

PLEASE COMPLETE THE FOLLOWING FORM AND RETURN YOUR REPLY TO THE ADDRESS STATED ABOVE. ALL INFORMATION WILL BE IN CONFIDENCE. YOUR IMMEDIATE ATTENTION IS GREATLY APPRECIATED.

-THE TOWN OF HUNTINGTON HOUSING AUTHORITY

TITLE OF POSITION HELD: _________________________________________________________

DATE HIRED:_________________ PRESENT STATUS:___________________________________

WAGES PAID (CIRCLE ONE): WEEKLY, BI-WEEKLY, SEMI-MONTHLY OR MONTHLY.

HOURLY RATE:_______________

IF HOURLY, INDICATE NUMBER OF HOURS WORKED PER WEEK: _______________

GROSS RATE OF PAY: $_________________

AMOUNT PAID GROSS YEAR TO DATE: $___________________ AS OF: __________________

SALARIED EMPLOYEE:_____________________________________________________________

DOES THE EMPLOYEE RECEIVE THE FOLLOWING?:

______NIGHT DIFFERENTIAL ______PERIODS OF VACATION WITH PAY

______COMMISSION ______TIPS ______BONUS ______OVER-TIME ______OTHER

IF YOU CHECKED ANY OF THE ABOVE, PLEASE SPECIFY: ___________________________________

__________________________________________________________________________________________.

__________________________________________________ DATE: _____________________ SIGNATURE OF AUTHORIZED PERSON


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EMPLOYMENT VERIFICATION FORM DATE: _____________________

APPLICANT/TENANT (PRINT NAME): ________________________________________________________

EMPLOYER’S NAME: _______________________________________________________________________

EMPLOYER’S ADDRESS: ________________________________________________________________

________________________________________________________________

I HEREBY AUTHORIZE MY EMPLOYER TO RELEASE ALL OF MY INCOME INFORMATION TO THE TOWN OF HUNTINGTON HOUSING AUTHORITY.

SOCIAL SECURITY NUMBER:_________________________________________________

SIGNATURE OF APPLICANT/TENANT:_______________________________________________________

FOR EMPLOYER’S USE ONLY

PLEASE COMPLETE THE FOLLOWING FORM AND RETURN YOUR REPLY TO THE ADDRESS STATED ABOVE. ALL INFORMATION WILL BE IN CONFIDENCE. YOUR IMMEDIATE ATTENTION IS GREATLY APPRECIATED.

-THE TOWN OF HUNTINGTON HOUSING AUTHORITY

TITLE OF POSITION HELD: _________________________________________________________

DATE HIRED:_________________ PRESENT STATUS:___________________________________

WAGES PAID (CIRCLE ONE): WEEKLY, BI-WEEKLY, SEMI-MONTHLY OR MONTHLY.

HOURLY RATE:_______________

IF HOURLY, INDICATE NUMBER OF HOURS WORKED PER WEEK: _______________

GROSS RATE OF PAY: $_________________

AMOUNT PAID GROSS YEAR TO DATE: $___________________ AS OF: __________________

SALARIED EMPLOYEE:_____________________________________________________________

DOES THE EMPLOYEE RECEIVE THE FOLLOWING?:

______NIGHT DIFFERENTIAL ______PERIODS OF VACATION WITH PAY

______COMMISSION ______TIPS ______BONUS ______OVER-TIME ______OTHER

IF YOU CHECKED ANY OF THE ABOVE, PLEASE SPECIFY: ___________________________________

__________________________________________________________________________________________.

__________________________________________________ DATE: _____________________ SIGNATURE OF AUTHORIZED PERSON

TOWN OF HUNGTINGTON HOUSING AUTHORITY 1-A LOWNDES AVENUE ● HUNTINGTON STATION, NY 11746 ● 631-427-6220 ● FAX 631-427-6288

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STATEMENT OF SELF EMPLOYMENT EARNINGS

NAME:_____________________________ DATE:______________

ADDRESS:___________________________________________________

SOCIAL SECURITY NUMBER:__________________________________

I _____________________ AM SELF EMPLOYED AS A _____________ AND I ESTIMATE THAT MY GROSS INCOME FOR THE NEXT 12 MONTHS WILL BE $_______________________.

I CERTIFY THAT THE ABOVE IS TRUE AND CORRECT AND I UNDERSTAND THAT ACCORDING TO FEDERAL LAW IT IS A CRIMINAL OFFENSE TO MAKE ANY FALSE STATEMENTS TO THE INTERNAL REVENUE SERVICE REGARDING MATTERS WITHIN THEIR JURISDICTION.

SIGNATURE: _____________________________ DATE: __________

STATE OF: ______________________________

COUNTY OF: ____________________________

SIGNED, THIS _________________________ DAY OF ________20_________

IN THE PRESENCE OF _____________________ (NOTARY’S SIGNATURE)

Kimberly LaCrette

Kimberly LaCrette



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TO BE COMPLETED BY AN ADULT (18 OR OLDER) WHO CURRENTLY HAS NO INCOME

HEAD OF HOUSEHOLD: _______________________________ DATE: __________ HOUSEHOLD NAME: _____________________________________

1. I HEREBY CERTIFY THAT I DO NOT INDIVIDUALLY RECEIVE INCOME FROM ANY OF THE FOLLOWING SOURCES:

o WAGES FROM EMPLOYMENT (INCLUDING COMMISSIONS, TIPS, BONUSES,

FEES, ETC.) o INCOME FROM OPERATION OF A BUSINESS o RENTAL INCOME FROM REAL OR PERSONAL PROPERTY o INTEREST OR DIVIDENDS FROM ASSETS o SOCIAL SECURITY PAYMENTS, ANNUITIES, INSURANCE POLICIES,

RETIREMENT FUNDS, DEATH BENEFITS o UNEMPLOYMENT OR DISABILITY PAYMENTS o PUBLIC ASSISTANCE PAYMENTS o PERIODIC ALLOWANCES SUCH AS ALIMONY, CHILD SUPPORT, OR GIFTS

RECEIVED FROM PERSONS NOT LIVING IN MY HOUSEHOLD o SALES FROM SELF-EMPLOYMENT RESOURCES (AVON, MARY KAY, ETC.) o ANY OTHER SOURCES NOT NAMED ABOVE

2. I CURRENTLY HAVE NO INCOME OF ANY KIND AND THERE IS NO IMMINENT

CHANGE EXPECTED IN MY FINANCIAL STATUS OR EMPLOYMENT STATUS DURING THE NEXT 12 MONTHS.

3. I WILL BE USING THE FOLLOWING SOURCES OF FUNDS TO PAY FOR RENT AND OTHER NECESSITIES: _______________________________________________________

UNDER PENALTY OF PERJURY, I CERTIFY THAT THE INFORMATION PRESENTED IN THIS CERTIFICATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. THE UNDERSIGNED FURTHER UNDERSTANDS THAT PROVIDING FALSE REPRESENTATIONS HEREIN CONSTITUTES AN ACT OF FRAUD. FALSE, MISLEADING OR INCOMPLETE INFORMATION MAY RESULT IN THE TERMINATION OF A LEASE AGREEMENT.

4. NAME OF APPLICANT: ___________________________________ DATE: _________________ 5. SIGNATURE OF APPLICANT: ___________________________________ 6. SIGNATURE OF NOTARY: ______________________________________ 7. STATE COMMISSIONS ISSUED: _________________________________ 8. COMMISSION EXPIRATION DATE: ______________________________

!


!

!

TO BE COMPLETED BY AN ADULT (18 OR OLDER) WHO CURRENTLY HAS NO INCOME

HEAD OF HOUSEHOLD: _______________________________ DATE: __________ HOUSEHOLD NAME: _____________________________________

1. I HEREBY CERTIFY THAT I DO NOT INDIVIDUALLY RECEIVE INCOME FROM ANY OF THE FOLLOWING SOURCES:

o WAGES FROM EMPLOYMENT (INCLUDING COMMISSIONS, TIPS, BONUSES,

FEES, ETC.) o INCOME FROM OPERATION OF A BUSINESS o RENTAL INCOME FROM REAL OR PERSONAL PROPERTY o INTEREST OR DIVIDENDS FROM ASSETS o SOCIAL SECURITY PAYMENTS, ANNUITIES, INSURANCE POLICIES,

RETIREMENT FUNDS, DEATH BENEFITS o UNEMPLOYMENT OR DISABILITY PAYMENTS o PUBLIC ASSISTANCE PAYMENTS o PERIODIC ALLOWANCES SUCH AS ALIMONY, CHILD SUPPORT, OR GIFTS

RECEIVED FROM PERSONS NOT LIVING IN MY HOUSEHOLD o SALES FROM SELF-EMPLOYMENT RESOURCES (AVON, MARY KAY, ETC.) o ANY OTHER SOURCES NOT NAMED ABOVE

2. I CURRENTLY HAVE NO INCOME OF ANY KIND AND THERE IS NO IMMINENT

CHANGE EXPECTED IN MY FINANCIAL STATUS OR EMPLOYMENT STATUS DURING THE NEXT 12 MONTHS.

3. I WILL BE USING THE FOLLOWING SOURCES OF FUNDS TO PAY FOR RENT AND OTHER NECESSITIES: _______________________________________________________

UNDER PENALTY OF PERJURY, I CERTIFY THAT THE INFORMATION PRESENTED IN THIS CERTIFICATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. THE UNDERSIGNED FURTHER UNDERSTANDS THAT PROVIDING FALSE REPRESENTATIONS HEREIN CONSTITUTES AN ACT OF FRAUD. FALSE, MISLEADING OR INCOMPLETE INFORMATION MAY RESULT IN THE TERMINATION OF A LEASE AGREEMENT.

4. NAME OF APPLICANT: ___________________________________ DATE: _________________ 5. SIGNATURE OF APPLICANT: ___________________________________ 6. SIGNATURE OF NOTARY: ______________________________________ 7. STATE COMMISSIONS ISSUED: _________________________________ 8. COMMISSION EXPIRATION DATE: ______________________________

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!!

!

PUBLIC ASSISTANCE INCOME VERIFICATION

HEAD OF HOUSEHOLD_______________________________ DATE:___________

SOCIAL SECURITY #: _______________________________________

PA CASE#: ________________________ FS CASE#: _________________________

ALL HOUSEHOLD MEMBERS ON CASE:

NAME: _____________________________ SSN: __________________________

NAME: _____________________________ SSN: __________________________!

NAME: _____________________________ SSN: __________________________!

NAME: _____________________________ SSN: __________________________!

NAME: _____________________________ SSN: __________________________!

NAME: _____________________________ SSN: __________________________

CURRENT ADDRESS: _____________________________________________

_____________________________________________

THE ABOVE NAMED HEAD OF HOUSEHOLD HAS APPLIED FOR, OR IS ALREADY PARTICIPATING IN THE FOLLOWING HOUSING PROGRAM.

( )PUBLIC HOUSING ( )HOUSING CHOICE VOUCHER

PLEASE PROVIDE THIS AGENCY WITH A COPY OF THE CURRENT BUDGET FOR THIS HOUSEHOLD AND FOR ANY OTHER HOUSEHOLD MEMBER AT THIS ADDRESS.

_______________________________________________ SIGNATURE OF APPLICANT/TENANT _______________________________________________ __________________ HOUSING AGENCY REPRESENTATIVE/PHONE # DATE !

TOWN OF HUNGTINGTON HOUSING AUTHORITY 1-A LOWNDES AVENUE ● HUNTINGTON STATION, NY 11746 ● PHONE 631-427-6220 ● FAX 631-427-6288

!!

CHILD SUPPORT VERIFICATION FORM TO WHOM IT MAY CONCERN, THE AGENCY/EMPLOYER OR PERSON PROVIDING INCOME MUST VERIFY THE INCOMES OF EACH ADULT TENANT APPLICANT. PARTICIPATION IN THE PROGRAM IS LIMITED TO INCOME ELIGIBLE FAMILIES AND RENT IS BASED ON A PERCENTAGE OF GROSS INCOME. PLEASE PROVIDE THE REQUESTED INFORMATION AS SOON AS POSSIBLE. BELOW IS A SIGNED AUTHORIZATION FOR RELEASE OF THIS INFORMATION TO THE HOUSING AUTHORITY. THANK YOU FOR YOUR COOPERATION.

SINCERELY, THE HHA.

I HEREBY RELEASE TO THE TOWN OF HUNTINGTON HOUSING AUTHORITY ALL INFORMATION RELATIVE TO MY INCOME. DOCKET #: ____________________________ DATE: _________________________ CHILD(RENS) NAME:___________________________ ___________________________ ___________________________ ___________________________ RESPONDENT’S NAME: ______________________________________________________ TENANT’S NAME: __________________________________________________________ SIGNATURE OF TENANT: ____________________________________________________ SOCIAL SECURITY #: ________________________________________________________

FOR CHILD SUPPORT ENFORCEMENT BUREAU USE ONLY GROSS AMOUNT: $_________________ THIS AMOUNT IS PAID (CHECK ONE):____WEEKLY ____BI-WEEKLY ____SEMI-MONTHLY ____MONTHLY EFFECTIVE DATE: ___________________ IS THE RESPONDENT CURRENTLY IN ARREARS?: YES / NO IF YES, HOW MUCH? $_____________________ WORKER’S SIGNATURE:_______________________________________________ !!! ! !

Kimberly LaCrette

Kimberly LaCrette


TOWN OF HUNTINGTON HOUSING AUTHORITY 1-A LOWNDES AVENUE ● HUNTINGTON STATION, NY 11746 ● PHONE 631-427-6220 ● FAX 631-427-6288

!!!

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VERIFICATION OF CHILDCARE EXPENSES

PLEASE KNOW THAT THIS EXPENSE CAN ONLY BE CLAIMED FOR CHILDREN UNDER THE AGE OF 13. THIS FORM ALSO MUST BE NOTARIZED AND ACCOMPANIED BY PROOF OF PAYMENT (AT LEAST 3 MONEY ORDERS, CANCELLED CHECKS, OR RECEPTS FROM THE DAY CARE PROVIDER.)

I, _____________________________________ (CHILDCARE PROVIDER) WHO RESIDES

AT _______________________________________________________________________________

DO HEREBY CERTIFY THAT I PROVIDE CHILDCARE FOR THE FOLLOWING CHILDREN:

1.____________________________________________

2.____________________________________________

3.____________________________________________

4.____________________________________________

TOTAL HOURS PER WEEK: ___________________________________

AMOUNT RECEIVED FOR CARE FROM THE FAMILY: $ __________ PER WEEK.

FULL-TIME SUMMER CARE OF SCHOOL AGE CHILDREN? YES/ NO (CIRCLE ONE)

_____________________________________________ _____________________ SIGNATURE OF CARE PROVIDER DATE

SIGNED THIS ______________________________ DAY OF __________________ 20____________

IN THE PRESENCE OF _______________________________. (SIGNATURE OF NOTARY)

SIGNATURE OF HEAD OF HOUSEHOLD ____________________________________________

!


STUDENT-ENROLLMENT VERIFICATION FORM

DATE: __________________ SCHOOL NAME& ADDRESS: STUDENT’S NAME: ___________________________________________ 1.____________________________________ ___________________________________________ 2.____________________________________

___________________________________________ 3.____________________________________ 4.____________________________________

HOME ADDRESS: ___________________________________________

___________________________________________

VERIFICATION OF STUDENT STATUS FEDERAL REGULATIONS REQUIRE THE HOUSING AUTHORITY TO VERIFY STUDENT STATUS OF HOUSEHOLD/FAMILY MEMBERS FOR THE DETERMINATION OF THE FAMILY’S ELIGIBILITY FOR RENTAL ASSISTANCE. PLEASE SUPPLY THE INFORMATION REQUESTED BELOW. I HEREBY REQUEST THAT YOU FURNISH THE HOUSING AUTHORITY INFORMATION REGARDING THE STUDENT(S) LISTED ABOVE. I UNDERSTAND THAT THIS INFORMATION WILL BE KEPT CONFIDENTIAL AND USED ONLY FOR THE PROGRAM PURPOSES.

-HUNTINGTON HOUSING AUTHORITY

____________________________________________________ SIGNATURE OF PARENT/GUARDIAN

FOR SCHOOL USE ONLY

STUDENT’S HOME ADDRESS: ___________________________________________________ ___________________________________________________ PARENT/GUARDIAN RESPONSIBLE FOR STUDENT: __________________________________ THIS IS TO CERTIFY THAT THE ABOVE LISTED STUDENT(S) IS ENROLLED AT THIS SCHOOL. NAME OF EDUCATIONAL INSTITUTION: ______________________________________________ _________________________________________ ______________________________________ AUTHORIZED SIGNATURE TITLE DATE: _____________________________ PHONE #: _____________________________

Kimberly LaCrette

Kimberly LaCrette



STUDENT-ENROLLMENT VERIFICATION FORM

DATE: __________________ SCHOOL NAME& ADDRESS: STUDENT’S NAME: ___________________________________________ 1.____________________________________ ___________________________________________ 2.____________________________________

___________________________________________ 3.____________________________________ 4.____________________________________

HOME ADDRESS: ___________________________________________

___________________________________________

VERIFICATION OF STUDENT STATUS FEDERAL REGULATIONS REQUIRE THE HOUSING AUTHORITY TO VERIFY STUDENT STATUS OF HOUSEHOLD/FAMILY MEMBERS FOR THE DETERMINATION OF THE FAMILY’S ELIGIBILITY FOR RENTAL ASSISTANCE. PLEASE SUPPLY THE INFORMATION REQUESTED BELOW. I HEREBY REQUEST THAT YOU FURNISH THE HOUSING AUTHORITY INFORMATION REGARDING THE STUDENT(S) LISTED ABOVE. I UNDERSTAND THAT THIS INFORMATION WILL BE KEPT CONFIDENTIAL AND USED ONLY FOR THE PROGRAM PURPOSES.

-HUNTINGTON HOUSING AUTHORITY

____________________________________________________ SIGNATURE OF PARENT/GUARDIAN

FOR SCHOOL USE ONLY

STUDENT’S HOME ADDRESS: ___________________________________________________ ___________________________________________________ PARENT/GUARDIAN RESPONSIBLE FOR STUDENT: __________________________________ THIS IS TO CERTIFY THAT THE ABOVE LISTED STUDENT(S) IS ENROLLED AT THIS SCHOOL. NAME OF EDUCATIONAL INSTITUTION: ______________________________________________ _________________________________________ ______________________________________ AUTHORIZED SIGNATURE TITLE DATE: _____________________________ PHONE #: _____________________________

Kimberly LaCrette

Kimberly LaCrette



!

VERIFICATION OF COLLEGE ENROLLMENT FORM

DATE: __________________ STUDENT’S NAME: _________________________________________

STUDENT’S SSN: _________________________________________ COLLEGE NAME: ___________________________________________ COLLEGE ADDRESS: ___________________________________________

___________________________________________

VERIFICATION OF STUDENT STATUS FEDERAL REGULATIONS REQUIRE THE HOUSING AUTHORITY TO VERIFY STUDENT STATUS OF HOUSEHOLD/FAMILY MEMBERS FOR THE DETERMINATION OF THE FAMILY’S ELIGIBILITY FOR RENTAL ASSISTANCE. PLEASE SUPPLY THE INFORMATION REQUESTED BELOW. ______________________________________ ______________________________________ STUDENT’S SIGNATURE HEAD OF HOUSEHOLD SIGNATURE

FOR COLLEGE USE ONLY THIS IS TO CERTIFY THAT THE ABOVE NAMED STUDENT IS ENROLLED AS A (CHECK ONE): _____ FULL-TIME STUDENT _____ PART-TIME STUDENT DATE OF ENROLLMENT: ____________________ ANTICIPATED GRADUATION DATE: ___________________ ASSISTANCE AND TUITION PER SEMESTER ASSISTANCE OF: $________________ (PLEASE LIST COST PER SEMESTER) TYPE TUITION BEFOG $____________ BOOKS $____________ G.I. BILL $____________ SUPPLIES $____________ NSDL $____________ EQUIPMENT $____________ WORK-STUDY $____________ TRANSPORT. $____________ OTHER $____________ OTHER $____________ IS THE STUDENT ENROLLED FOR SUMMER MONTHS?: _____YES _____NO NAME OF EDUCATIONAL INSTITUTION:__________________________________________ ___________________________________ _____________________________________ TELEPHONE NUMBER AUTHORIZED SIGNATURE I HEREBY REQUEST THAT YOU FURNISH THE HOUSING AUTHORITY INFORMATION REGARDING THE STUDENT LISTED ABOVE.

TOWN OF HUNTINGTON HOUSING AUTHORITY 1A LOWNDES AVENUE HUNTINGTON STATION N.Y. 11746

PHONE (631) 427-6220 – FAX (631) 427-6288

FULL TIME COLLEGE STUDENT STATUS

VERIFICATION

Please provide a LETTER from the school’s REGISTRAR OFFICE indicating current F/T student status of adult household member. An acceptance letter, bill or schedule will NOT be considered).

Paperwork Reduction Notice: Public reporting burden for this collection of information is estimated to average 7 minutes

per response. This includes the time for respondents to read the document and certify, and any recordkeeping burden. This

information will be used in the processing of a tenancy. Response to this request for information is required to receive

benefits. The agency may not collect this information, and you are not required to complete this form, unless it displays

a currently valid OMB control number. The OMB Number is 2577-‐0266, and expires 08/31/2016.

NOTICE TO APPLICANTS AND PARTICIPANTS OF THE FOLLOWING HUD RENTAL ASSISTANCE PROGRAMS:

Public Housing (24 CFR 960) Section 8 Housing Choice Voucher, including the Disaster Housing Assistance Program (24 CFR 982) Section 8 Moderate Rehabilitation (24 CFR 882) Project-Based Voucher (24 CFR 983)

The U.S. Department of Housing and Urban Development maintains a national repository of debts owed to Public Housing Agencies (PHAs) or Section 8 landlords and adverse information of former participants who have voluntarily or involuntarily terminated participation in one of the above-listed HUD rental assistance programs. This information is maintained within HUD’s Enterprise Income Verification (EIV) system, which is used by Public Housing Agencies (PHAs) and their management agents to verify employment and income information of program participants, as well as, to reduce administrative and rental assistance payment errors. The EIV system is designed to assist PHAs and HUD in ensuring that families are eligible to participate in HUD rental assistance programs and determining the correct amount of rental assistance a family is eligible for. All PHAs are required to use this system in accordance with HUD regulations at 24 CFR 5.233.

HUD requires PHAs, which administers the above-listed rental housing programs, to report certain information at the conclusion of your participation in a HUD rental assistance program. This notice provides you with information on what information the PHA is required to provide HUD, who will have access to this information, how this information is used and your rights. PHAs are required to provide this notice to all applicants and program participants and you are required to acknowledge receipt of this notice by signing page 2. Each adult household member must sign this form.

What information about you and your tenancy does HUD collect from the PHA? The following information is collected about each member of your household (family composition): full name, date of birth, and Social Security Number.

The following adverse information is collected once your participation in the housing program has ended, whether you voluntarily or involuntarily move out of an assisted unit:

1. Amount of any balance you owe the PHA or Section 8 landlord (up to $500,000) and explanation for balance owed (i.e. unpaid rent, retroactive rent (due to unreported income and/ or change in family composition) or other charges such as damages, utility charges, etc.); and

2. Whether or not you have entered into a repayment agreement for the amount that you owe the PHA; and 3. Whether or not you have defaulted on a repayment agreement; and 4. Whether or not the PHA has obtained a judgment against you; and 5. Whether or not you have filed for bankruptcy; and 6. The negative reason(s) for your end of participation or any negative status (i.e., abandoned unit, fraud, lease

violations, criminal activity, etc.) as of the end of participation date.

U.S. Department of Housing and Urban Development Office of Public and Indian Housing

DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONS

OMB No. 2577-0266 Expires 08/31/2016

08/2013 Form HUD-52675

2

Who will have access to the information collected? This information will be available to HUD employees, PHA employees, and contractors of HUD and PHAs.

How will this information be used? PHAs will have access to this information during the time of application for rental assistance and reexamination of family income and composition for existing participants. PHAs will be able to access this information to determine a family’s suitability for initial or continued rental assistance, and avoid providing limited Federal housing assistance to families who have previously been unable to comply with HUD program requirements. If the reported information is accurate, a PHA may terminate your current rental assistance and deny your future request for HUD rental assistance,

subject to PHA policy.

How long is the debt owed and termination information maintained in EIV? Debt owed and termination information will be maintained in EIV for a period of up to ten (10) years from the end of participation date.

What are my rights? In accordance with the Federal Privacy Act of 1974, as amended (5 USC 552a) and HUD regulations pertaining to its implementation of the Federal Privacy Act of 1974 (24 CFR Part 16), you have the following rights: 1. To have access to your records maintained by HUD, subject to 24 CFR Part 16. 2. To have an administrative review of HUD’s initial denial of your request to have access to your records maintained

by HUD. 3. To have incorrect information in your record corrected upon written request. 4. To file an appeal request of an initial adverse determination on correction or amendment of record request within

30 calendar days after the issuance of the written denial. 5. To have your record disclosed to a third party upon receipt of your written and signed request.

What do I do if I dispute the debt or termination information reported about me? If you disagree with the reported information, you should contact in writing the PHA who has reported this information

about you. The PHA’s name, address, and telephone numbers are listed on the Debts Owed and Termination Report. You have a right to request and obtain a copy of this report from the PHA. Inform the PHA why you dispute the

information and provide any documentation that supports your dispute. HUD's record retention policies at 24 CFR Part 908and 24 CFR Part 982 provide that the PHA may destroy your records three years from the date your participation in the

program ends. To ensure the availability of your records, disputes of the original debt or termination information must bemade within three years from the end of participation date; otherwise the debt and termination information will be presumed correct. Only the PHA who reported the adverse information about you can delete or correct your record.

Your filing of bankruptcy will not result in the removal of debt owed or termination information from HUD’s EIV system. However, if you have included this debt in your bankruptcy filing and/or this debt has been discharged by the bankruptcy court, your record will be updated to include the bankruptcy indicator, when you provide the PHA with documentation of your bankruptcy status.

The PHA will notify you in writing of its action regarding your dispute within 30 days of receiving your written dispute. If the PHA determines that the disputed information is incorrect, the PHA will update or delete the record. If the PHA determines that the disputed information is correct, the PHA will provide an explanation as to why the information is correct.

This Notice was provided by the below-listed PHA:

I hereby acknowledge that the PHA provided me with the Debts Owed to PHAs & Termination Notice:

Signature Date

Printed Name

OMB No. 2577-0266 Expires 08/31/2016

08/2013 Form HUD-52675

Kimberly LaCrette


Paperwork Reduction Notice: Public reporting burden for this collection of information is estimated to average 7 minutes

per response. This includes the time for respondents to read the document and certify, and any recordkeeping burden. This

information will be used in the processing of a tenancy. Response to this request for information is required to receive

benefits. The agency may not collect this information, and you are not required to complete this form, unless it displays

a currently valid OMB control number. The OMB Number is 2577-‐0266, and expires 08/31/2016.

NOTICE TO APPLICANTS AND PARTICIPANTS OF THE FOLLOWING HUD RENTAL ASSISTANCE PROGRAMS:

Public Housing (24 CFR 960) Section 8 Housing Choice Voucher, including the Disaster Housing Assistance Program (24 CFR 982) Section 8 Moderate Rehabilitation (24 CFR 882) Project-Based Voucher (24 CFR 983)

The U.S. Department of Housing and Urban Development maintains a national repository of debts owed to Public Housing Agencies (PHAs) or Section 8 landlords and adverse information of former participants who have voluntarily or involuntarily terminated participation in one of the above-listed HUD rental assistance programs. This information is maintained within HUD’s Enterprise Income Verification (EIV) system, which is used by Public Housing Agencies (PHAs) and their management agents to verify employment and income information of program participants, as well as, to reduce administrative and rental assistance payment errors. The EIV system is designed to assist PHAs and HUD in ensuring that families are eligible to participate in HUD rental assistance programs and determining the correct amount of rental assistance a family is eligible for. All PHAs are required to use this system in accordance with HUD regulations at 24 CFR 5.233.

HUD requires PHAs, which administers the above-listed rental housing programs, to report certain information at the conclusion of your participation in a HUD rental assistance program. This notice provides you with information on what information the PHA is required to provide HUD, who will have access to this information, how this information is used and your rights. PHAs are required to provide this notice to all applicants and program participants and you are required to acknowledge receipt of this notice by signing page 2. Each adult household member must sign this form.

What information about you and your tenancy does HUD collect from the PHA? The following information is collected about each member of your household (family composition): full name, date of birth, and Social Security Number.

The following adverse information is collected once your participation in the housing program has ended, whether you voluntarily or involuntarily move out of an assisted unit:

1. Amount of any balance you owe the PHA or Section 8 landlord (up to $500,000) and explanation for balance owed (i.e. unpaid rent, retroactive rent (due to unreported income and/ or change in family composition) or other charges such as damages, utility charges, etc.); and

2. Whether or not you have entered into a repayment agreement for the amount that you owe the PHA; and 3. Whether or not you have defaulted on a repayment agreement; and 4. Whether or not the PHA has obtained a judgment against you; and 5. Whether or not you have filed for bankruptcy; and 6. The negative reason(s) for your end of participation or any negative status (i.e., abandoned unit, fraud, lease

violations, criminal activity, etc.) as of the end of participation date.

U.S. Department of Housing and Urban Development Office of Public and Indian Housing

DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONS

OMB No. 2577-0266 Expires 08/31/2016

08/2013 Form HUD-52675

Kimberly LaCrette

Text

2

Who will have access to the information collected? This information will be available to HUD employees, PHA employees, and contractors of HUD and PHAs.

How will this information be used? PHAs will have access to this information during the time of application for rental assistance and reexamination of family income and composition for existing participants. PHAs will be able to access this information to determine a family’s suitability for initial or continued rental assistance, and avoid providing limited Federal housing assistance to families who have previously been unable to comply with HUD program requirements. If the reported information is accurate, a PHA may terminate your current rental assistance and deny your future request for HUD rental assistance,

subject to PHA policy.

How long is the debt owed and termination information maintained in EIV? Debt owed and termination information will be maintained in EIV for a period of up to ten (10) years from the end of participation date.

What are my rights? In accordance with the Federal Privacy Act of 1974, as amended (5 USC 552a) and HUD regulations pertaining to its implementation of the Federal Privacy Act of 1974 (24 CFR Part 16), you have the following rights: 1. To have access to your records maintained by HUD, subject to 24 CFR Part 16. 2. To have an administrative review of HUD’s initial denial of your request to have access to your records maintained

by HUD. 3. To have incorrect information in your record corrected upon written request. 4. To file an appeal request of an initial adverse determination on correction or amendment of record request within

30 calendar days after the issuance of the written denial. 5. To have your record disclosed to a third party upon receipt of your written and signed request.

What do I do if I dispute the debt or termination information reported about me? If you disagree with the reported information, you should contact in writing the PHA who has reported this information

about you. The PHA’s name, address, and telephone numbers are listed on the Debts Owed and Termination Report. You have a right to request and obtain a copy of this report from the PHA. Inform the PHA why you dispute the

information and provide any documentation that supports your dispute. HUD's record retention policies at 24 CFR Part 908and 24 CFR Part 982 provide that the PHA may destroy your records three years from the date your participation in the

program ends. To ensure the availability of your records, disputes of the original debt or termination information must bemade within three years from the end of participation date; otherwise the debt and termination information will be presumed correct. Only the PHA who reported the adverse information about you can delete or correct your record.

Your filing of bankruptcy will not result in the removal of debt owed or termination information from HUD’s EIV system. However, if you have included this debt in your bankruptcy filing and/or this debt has been discharged by the bankruptcy court, your record will be updated to include the bankruptcy indicator, when you provide the PHA with documentation of your bankruptcy status.

The PHA will notify you in writing of its action regarding your dispute within 30 days of receiving your written dispute. If the PHA determines that the disputed information is incorrect, the PHA will update or delete the record. If the PHA determines that the disputed information is correct, the PHA will provide an explanation as to why the information is correct.

This Notice was provided by the below-listed PHA:

I hereby acknowledge that the PHA provided me with the Debts Owed to PHAs & Termination Notice:

Signature Date

Printed Name

OMB No. 2577-0266 Expires 08/31/2016

08/2013 Form HUD-52675

Kimberly LaCrette


Documents

DOCUMENTS REQUIRED FOR YOUR RECERTIFICATION PACKET · 1A Lowndes Avenue Huntington Station, N.Y. 11746 (631) 427-6220 - Fax (631) 427-6288 DOCUMENTS REQUIRED FOR YOUR RECERTIFICATION